Laserfiche WebLink
74- 2- <br /> SERVICE REQUEST (EH 00 61) Revised 8/23/93 <br /> � n <br /> EEID # RECORD ID # 1�Jl INVOICE # � VI G� <br /> FACILITY NAME CaL�2I'�+7Wf7 /-11- BILLING PARTY Y N <br /> SITE ADDRESS ��� ���. ��/d lie- <br /> CITY l-��� �z CA ZIP <br /> OWNER/OPERATOR BILLING PARTY (/ Y / N <br /> DBA PHONE #1 <br /> ADDRESS t� 2— ✓C �e- / eCG 1, /4 L�P-- PHONE #2 <br /> CITY /�Sy� STATE C�A ZIP <br /> APN # Land Use Application # <br /> BOS Dist Location Code <br /> CONTRACTOR and/or <br /> SERVICE REQUESTOR BILLING PARTY Y <br /> DBA ( ��Jl/ �����/� �� PHONE #1 {sem / >3Y7- f5:117-7 <br /> MAILING ADDRESS / ��Z Z— !, O / ` "2 FAX # ( ) <br /> CITY �/ �1�Y1�Q STATE ZIP / ��- d(� <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identifie"t j ALING PARTY on <br /> Page 1 of this form. ��++CCRFI-Fjvm� <br /> 1 also certify that I have prepared this application and that the work to be performed will be don SEgtclor2larltfR[y}ith all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, State and Federal laws. 1 U SAN J()A QUI ��JJJJ3� <br /> ,NVIP Uauc,T AL TI j S RV T k <br /> APPLICANT'S SIGNATURE I f Ems_ <br /> ' a it <br /> G 2 G 1 Date- 12 - 95N DIVISION <br /> Title: <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> environmental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code S22- <br /> Assigned to QQ Employee # �/ «— Date _/� /_ <br /> Date Service Completed l / _/ �� Further Action Required: Y / �1 PROGRAM ELEMENT <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By REHS _/ / SUPV _/ / ACCT / / UNIT CLK _/ / <br />